Healthcare Provider Details

I. General information

NPI: 1396797296
Provider Name (Legal Business Name): PAUL HALLEMANN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1346 CLARKSON CLAYTON CTR
ELLISVILLE MO
63011-2145
US

IV. Provider business mailing address

607 DEWEY AVE NW STE 300
GRAND RAPIDS MI
49504-7335
US

V. Phone/Fax

Practice location:
  • Phone: 636-227-5200
  • Fax: 636-227-5202
Mailing address:
  • Phone: 616-356-5000
  • Fax: 616-356-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number104500
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: